ACT and ADJUST: Evaluating a Layered Emergency Triage Model Integrating Structured Scoring and Physician Judgment

Background Triage in emergency departments (EDs) must extend beyond simply prioritizing patients for physician evaluation—it should also support the efficient allocation of limited clinical resources in fast-paced, high-pressure settings. This study evaluates a dual-layer triage model that integrates two complementary approaches: the structured, nurse-led Acuity Categorization Tool (ACT) and the physician-driven Adaptive Judgment of Urgency and Streaming (ADJUST). The model combines standardized initial assessment with dynamic, context-sensitive reassessment grounded in clinical insight and operational realities. Methods We retrospectively analyzed 53,651 consecutive ED encounters to assess the performance of ACT and ADJUST in identifying patients requiring intensive care unit (ICU) admission. Sensitivity, specificity, and reclassification rates were calculated using real-time triage documentation. To reflect the model’s distinct urgency thresholds, prognostic performance was evaluated exclusively for the highest acuity category (Red). Analyses included all encounters with complete data; documentation gaps in very high-acuity cases were acknowledged, as immediate clinical action often preempted formal triage. Results Among 409 ICU transfers, ACT demonstrated higher sensitivity (81.2%) than ADJUST (68.6%), aligning with its role in early detection. In contrast, ADJUST achieved greater specificity (96.0% vs. 85.9%), supporting more selective prioritization and improved resource alignment. Across the cohort, 45.3% of ACT classifications were downgraded and 3.6% upgraded by ADJUST. In a subset of 42,881 encounters with complete documentation, 20.9% of ICU patients initially flagged as Red by ACT were reclassified to lower acuity by ADJUST. Nearly half of all ADJUST evaluations occurred within 15 minutes of ACT. Conclusion This dual-layer triage model illustrates the complementary strengths of protocol-based scoring and physician judgment. ACT supports efficient and standardized initial triage, while ADJUST offers targeted refinement through clinical expertise and system-level awareness. The timing and reclassification patterns observed suggest that the two layers often functioned as an integrated, real-time decision-making process rather than discrete sequential steps. These findings align with performance benchmarks for established triage systems and suggest that integrated frameworks combining structured assessment with clinical discretion warrant further evaluation to improve acuity detection and care coordination in emergency care. Clinical trial number: not applicable.